MMA SRC #11, Attachment 1: Network Development and ... 08/MAGELLAN/Exhibit A-4-… · 1—Magellan Complete Care Network Development & Management Plan MMA SRC #11, Attachment 1: Magellan

MMA SRC #11, Attachment 1: Network Development and

Management Plan

1—Magellan Complete Care Network Development & Management Plan

MMA SRC #11, Attachment 1: Magellan Complete Care Network Development and Management Plan

I. General Provisions

Magellan Complete Care‘s provider network is one of our most valuable assets and we are committed to a collaborative approach to its continued development and management. This approach is built on: • Providers are appropriately contracted with Magellan Complete Care of Florida through the

Agency for Health Care Administration (AHCA) approved written, signed agreements, and evaluated through NCQA compliant credentialing/recredentialing program

• Effective Provider collaboration • An ongoing and evolving understanding of populations and sub-populations • A comprehensive and robust network of providers • High quality network management • A comprehensive array of covered services and supports • Ongoing provider support and technical assistance

II. Annual Network Plan Content

The Managed Care Plan’s annual network plan shall include the Managed Care Plan’s processes to develop, maintain and monitor an appropriate provider network that is sufficient to provide adequate access to all services covered under this Contract. Processes for Development, Maintenance and Monitoring Magellan Complete Care’s annual network plan includes Magellan Complete Care’s processes to develop, maintain and monitor an appropriate provider network that is sufficient to provide adequate and compliant access to all required health care services covered under the Contract. These processes and policies include but are not limited to: • Provider Adequacy & Accessibility Standards, appropriate to number of providers and related

geographic displacement to time & distance to access such providers as it pertains to specialty designation, qualifications and training

• Medicaid enrollment

• Utilization of covered services by enrollees • Provider Credentialing and Re-credentialing • Network Changes and updates


• Open panel providers • Closed panel providers • Provider Network Standards • Provider Contract and Network Compliance • Provider Network Participation and Appeals • Provider Termination and Continuity of Care • Provider Diversity & Cultural Competency Plan

Development

Enrollees with Acute and Chronic Physical, Mental and Behavioral Health disposition carry a disproportionate illness burden and pose significant challenges in managing their Health and Wellness. Magellan Complete Care became a leading managed Medicaid specialty plan for the comprehensive care of enrollees with Medical, Mental and Behavioral Health experiences. Magellan Complete Care‘s network development and management plan is designed to support our goals for serving enrollees with multiple and complex Health Care conditions including:

• Ensure that all covered services are available and accessible to members in a timely manner,

including acute and primary, institutional and community-based long-term services and supports (LTSS), behavioral health, and special Medicaid services

• Providers who maintain specialization and expertise in early childhood, youth, geriatric and women’s health specialty services

• Providers with specialization of training, education & experience with MCC FL members • Development, coordination and support of Provider-based Health Homes for MCC FL members

with complex health and social needs • The development and coordination with AHCA for implementation of behavioral health homes

for individuals with serious mental illness. • Addiction and Recovery Treatment Services (ARTS) providers across appropriate levels of care

such as, detoxification services, residential treatment services, and Substance Use disorder (SUD) outpatient services

• Improving the coordination of care between and satisfaction of providers caring for the complex enrollees of care by providing better access and care coordination for this population

• Decreasing overutilization of institutional/facility-based care and increase community tenure for these enrollees

• Creating system transparency and accountability through data sharing and outcome tracking

When developing healthcare service delivery networks, Magellan Complete Care determines and identifies network needs by gathering pertinent information such as, contract requirements, health care trends, enrollee access needs and industry access reports, enrollee input, utilization trends, etc. that directly impacts our approach to on-going network development. Magellan has successfully used this approach to develop networks in a wide range of environments. In addition to our work in Florida, our approach has also been successful in states as diverse in population and programs as Arizona, Iowa, Pennsylvania, Nebraska, and Louisiana. Utilizing targeted provider trainings, town hall, webinars, provider relations site visits, and prompt day-to-day issue resolution, we


develop strong and mutually respectful relationships to achieve a provider network that reflects the diversity and comprehensive healthcare needs of our membership.

Throughout 2016, Network personnel have met with Health Systems, Hospitals, Rehabilitation Hospitals, Community Based Providers, CMHCs and FQHCs to better understand the patterns of care of our population. We are working closely with the CMHC’s, LTSS, Nursing and RHC facilities as well as FQHCs to manage potential membership and will continue to adjust our network delivery model of providers, practitioners and specialists to accommodate our members’ comprehensive medical needs.

Our overarching network development and provider management goal is to ensure timely access to quality health care services for all enrollees. Our specific methods used to achieve these goals are described following this summary of our provider development program.

Maintenance Provider Optimization Delivery System (PODS)

Our PODS team is at the core of our provider network management and relations activities in Florida. The integrated PODS teams are organized for each region in the State. Each of the teams will have a Contract Manager, Field Network Coordinators and a Contract Network Coordinator for each region reporting to a Director of Network Management who reports to the National Vice President of Network Development. Additionally each region has a Provider Support Specialist who is responsible for addresses the clinical and quality practice needs of the network. As licensed behavioral health clinicians and Registered Nurses, they bring value to the network through offering a host of practice transformation activities by employing principles of practice facilitation. Lastly each region has an assigned Provider Relations Manager who addresses the business and operational needs of the providers. The PRM’s focus on claims resolution, education around payment, authorizations, billing, and compliant resolution. Magellan Complete Care offers this approach because it provides the optimal structure to accentuate our existing Medical and Behavioral health provider knowledge base, our existing knowledge of resources, community, and Integrated Health Home clinics (IHH). The same teams will also be responsible for all medical and behavioral health providers, facilities, and ancillary provider in their assigned regions. The teams are charged with contracting, providing management and technical assistance, conducting site visits, and providing education to providers in the network. This model also shows our continued commitment to our high touch involvement with our providers in order to maximize plan operations and health care outcomes for our enrollees. To ensure Magellan Complete Care is providing the clinical support, the PSS team conducts on site education such as: treating individuals living with serious mental illness, care coordination, psychopharmacology and much more. The PSS team also builds a connection between the MCC care coordination team and the providers to ensure communication and collaboration to support positive outcomes for the members.

The following points clearly demonstrate the value of the PODS approach:

• Provider collaboration and information sharing is the foundation for the success of our model. PODS revolves around provider engagement by building solid and meaningful relationships


which will ultimately drive provider satisfaction and Magellan Complete Care‘s success through membership growth and quality of care.

• PODS creates a structure for integration and provider collaboration of medical and behavioral health providers as well as community support services. This integrative structure provides a primary account manager for all business units when dealing with issue identification and resolution, and medical and quality management initiatives. This will offer a seamless approach to the provider community and Magellan’s enrollees.

• Magellan Complete Care believes a hands on approach is necessary in order to provide support to the network to ensure positive health outcomes. Our locally based teams know the providers and their local communities which provides a unique connectedness and ability to service the network with a regionally specific approach.

• PODS individuals are cross trained teams of network and provider relations specialists that will focus on specific areas of the State and regions in providing continuity and accessibility for the providers to address questions and concerns with the plan.

• PODS specialists work in close coordination with the Magellan enrollees assigned Health Guide. • PODS specialists are accountable to Magellan Complete Care‘s departments, including

credentialing, health services (utilization management, care coordination, case management, disease management, and health promotion), claims, marketing, training, quality, customer service, and other department representatives, as appropriate. They will address issues related to network access and monitoring availability, quality issues, continuous performance improvement, innovative reimbursement methodologies, and new program development.

• The POD structure offers a mechanism to enhance seamless collaboration with all functional areas to ensure quick and efficient issue resolution within the provider networks.

• Magellan Complete Care embraced this PODS methodology as an emerging cutting edge approach for the development and continuous improvement of the Network Management Integration Model.

The PODS model will foster healthcare integration at the systems and services level by ensuring superior collaboration and communication with our providers designed to lead to better healthcare outcomes. Our continuous monitoring of our network for sufficiency and capacity will lead to increased enrollee and provider satisfaction and will solicit strong opportunity for cost savings. As an integrated health plan, Magellan Complete Care believes it is our responsibility to promote integration of care and build capacity within the network to move in this direction. The PSS team is trained on practice facilitation (provider engagement, assessment, goal setting, practice improvement strategies and support) focused on impacting the triple aim of healthcare through implementation of an integrated practice model. Additionally the PSS team assumes a “broker” role between PCP’s and behavioral health providers to: develop referrals options, strengthen communication pathways, and provide cross training of the resources available in communities to improve the health of the members.

The PODS model allows designated staff members assigned to specific regions to develop an intimate knowledge of the provider network structure in their assigned region. This will allow Magellan Complete Care to assist providers that may be unfamiliar with providing services in a managed care environment. Staff will be aware of new provider offices which open in their region or new providers joining existing practices. They will also monitor local medical boards for new physicians and new graduates entering


the workplace. This will ensure we are reaching out and providing training opportunities for new providers unfamiliar with managed care so that they can successfully provide services in a managed care environment.

Provider Network Training

Magellan was created for the sole purpose of managing and delivering state-of-the-art integrated medical and behavioral health services for Florida Medicaid enrollees with Medical and Behavioral Health Experiences and their family members regardless of eligibility category.

• Magellan integrates the Florida-specific and national capabilities of its affiliate health care

companies in Medical and Behavioral health, Radiology, Pharmacy, and Medicaid managed care services under the parent company Magellan Health Services, Inc. (Magellan Health) in order to ensure that all covered services are available and accessible to members in a timely manner, including acute and primary, institutional and community-based long-term services and supports (LTSS), behavioral health, and special Medicaid services.

Our combined expertise makes us uniquely qualified to serve all the health care needs of enrollees with Medical and Behavioral Health experiences in all eligibility categories. Magellan Complete Care plans a multi-faceted education effort delivered through various approaches and media that is specifically designed to holistically care for this fragile population. Enrollees with Medical, Mental and Behavioral Health experiences carry a disproportionate illness burden and pose significant challenges in management and they require deep clinical expertise combined with new models of care, including close care coordination in order to ensure the best chance at recovery and living a productive life.

Our provider education plan has been thoughtfully developed to support us in meeting our goals including:

• Improving the overall health, longevity and well-being of the enrollees • Increasing the knowledge base of the provider network of the unique needs of our members

and best practices. • Reduce stigma through increasing awareness related to behavioral health and recovery

principles • Improving the coordination of care between and satisfaction of providers caring for these

members and • Lowering the cost of care by providing better access and care coordination for this vulnerable

population • Decreasing overutilization of institutional/facility-based care and increase community tenure for

these enrollees • Creating system transparency and accountability through data sharing and outcome tracking

Magellan Complete Care has provided extensive training to network providers both at time of initial contracting (within 30 days of provider active status which coincides with the AHCA roll-out schedule) and on an ongoing basis to ensure that Magellan Complete Care‘s high quality standards are met by providers and facilities that interact and provide services to enrollees. These trainings include Face to Face town halls, community outreach trainings, online webinars and one on one office visits. This allows


the entire network of providers to have the ability to attend a training that is convenient to them and their office staff. Training includes both medical and behavioral health topics, managed Medicaid concepts and focuses on our philosophy of meeting all of an individual‘s needs across a comprehensive continuum of care whether medical, behavioral or social in nature. Themes of independent living, recovery and resiliency, person-centered planning, cultural competency, accessibility and accommodations, wellness and prevention principles, and trauma informed services are embedded throughout the training models.

The provider orientation meetings will include information on all aspects of the operations of Magellan Complete Care including but not limited to the following topics:

• Network Support Resources • Customer Service Center • Member Eligibility and Enrollment Assignment • Member Benefits • Outreach and Marketing (Do’s and Don’ts) • Claims and Billing • Clinical operations, care coordination and child health check up • Complaints, Grievances, and Appeals • Fraud, Waste, and Abuse • Direct training for providers surrounding the medical/psychiatric aspects of caring for victims

and perpetrators of physical/mental abuse, neglect, exploitation and domestic violence.

All providers are required to sign a written acknowledgement of their participation in the training and will be presented with Provider Operations manual and other important handouts. Provider training and orientation slide decks and materials will also be available on the Magellan Complete Care website for providers to review on demand. Magellan Complete care will document all provider training activity including date, attendees, presenter, and topics covered. In addition to providing online courses, instructor-led training sessions, customized technical assistance, and self-study alternatives, we also will optimize learning by utilizing the clinical Provider Support Specialists to educate both medical and behavioral health providers on plan operations and policies health topics as well as to coordinate community-based events around health promotion. Additionally the Provider Support Specialists focus on practice improvement and integration of care to help guide providers in their adoption of fully integrated care models. They also provide training and information around key community resources in their local communities to address the member’s social determinants of health which are an extension of tradition healthcare. Similarly, we will utilize medical and behavioral health subject matter experts to provide learning opportunities to primary care providers, placing special emphasis on cultivating our steadfast commitment to the recovery philosophy.

We also recognize that learning can take place in less formal environments. For this reason, we emphasize that our Field network team to attend provider inquiries as they arise within their assigned regions. This provides a familiar face to the provider office and allows Magellan to develop long lasting collaborative relationships. Frequent communication with our provider network through provider newsletters and educational mailings will result in a more informed health care system.


In the interest of creating a transparent and collaborative whole-health system of care, our learning program is also designed around interdisciplinary learning and community collaboration. Magellan Complete Care staff members, network providers, primary care network providers, enrollees, family members, system partners, and a multitude of valued stakeholders will have the opportunity to participate in cross-disciplinary learning through ongoing training events. As a result, participants will also learn from each other and training content becomes more culturally relevant for all stakeholders. Some of these include the following:

• Enrollees providing input into curriculum development, as well as facilitating classes as subject matter experts

• Learning specialists co-facilitating topics with family members • Medical and Behavioral and primary care providers coming together to educate about chronic

health conditions and the implications for enrollees with complex and chronic health care conditions.

All providers will be invited to quarterly training programs. These programs may focus on specific areas of concern for the Magellan Complete Care team or serve as refreshers on key items. Training may be delivered in-person or facilitated through written or electronic communication. Depending on the content, invitations may only be extended to the relevant sub-group of the provider network. A summary of these training sessions will be posted to the provider portal of the Magellan Complete Care Web site and the Provider Network team will be happy to review the content with providers who are unable to attend. Participation in these training sessions is not mandatory. Topics to be considered for training include:

• QI/clinical Training • Technical assistance • Magellan Complete Care peer connections • Claims and encounters • Provider portal tutorial and refresher.

All providers will be requested to attend an annual refresher course to review updates to the Provider Handbook and any other key issues that are important for providers to know. Some annual training may be initiated via written or electronic means. The Provider Network team will work to schedule ad hoc time with providers that are unable to attend. Additional training topics may include:

• Provider recognition initiatives • Incident management training • Cultural competency training • Compliance and fraud/waste/abuse training • Disaster recovery.

Fraud, Waste and Abuse

Magellan aggressively pursues allegations of fraud, waste, and abuse. Training occurs at the initial level during the orientation and then more comprehensively training during our “in-office” visits. Both trainings emphasize providers’ responsibilities to comply with all state and federal regulations and Magellan’s role in the prevention, detection and reporting of fraud, waste, abuse and overpayment to


the State and Medicaid Integrity agencies. The comprehensive training was developed and approved by the Local Compliance Officer and the SIU Unit for the use by Network. The Magellan Complete Care Anti-Fraud and Compliance Plan outlines Magellan’s program and the mission of which is the aggressive pursuit of suspected fraud, waste, abuse, and overpayments.

For a period of at least twelve (12) months following the implementation of this Contract, Magellan will conduct and or make available a monthly education and training for providers regarding claims submission and payment processes, which shall include, but not be limited to, an explanation of common claims submission errors and how to avoid those errors. Such period may be extended as determined necessary by the Department. The provider training on fraud, waste, abuse and overpayment includes such topics as:

• What is Fraud, Waste, Abuse (FWA) • Exclusion and Debarment • Medicaid Disclosure Requirements • Examples of FWA and Overpayments • What You Can Do – Provider Roles & Responsibilities • What Magellan Will Do – Magellan’s Responsibilities • How to Report FWA and Overpayments • Federal and State Government Oversight Agencies • Additional Information about FWA

Monitoring

Magellan Complete Care Network staff collaborates with quality staff to develop an annual provider plan, which addresses provider interface, and outreach, incorporates provider orientation and ongoing training, and identifies opportunities for provision of ongoing support to providers, as well as support of quality initiatives. As part of the Provider Plan, Network staff continuously monitor, report, and adjust network sufficiency as appropriate. Magellan recognizes that there are some geographical areas that lack a sufficient number of particular specialties. Therefore Magellan will continue to explore opportunities to address such situations through contracting, management, use of Single Case Agreements and Non-emergency transportation to ensure all enrollees maintain sufficient access to providers.

Results of the network sufficiency analysis help ensure service types and capacity meet system needs including culturally diverse priority populations and persons with special needs. Magellan will meet all of the following monitoring requirements as part the AHCA contract, including, but not limited to: Acute and primary, institutional and community-based long-term services and supports (LTSS), behavioral health, and special Medicaid services, credentialing, re-credentialing, claims, access to services and fraud, waste and abuse. In addition to Magellan maintains and monitors the capacity of providers that serve enrollees, including the following:


Quest Analytics geographical access analysis results, density analysis, current and

anticipated enrollment and penetration data Utilization data, complaint and grievance/appeals data Claims/billing disputes Managed Care Plan’s administrative functions, policies and procedures such as service

authorizations, claims payment. Quality of Care delivered to enrollee’s Access and Availability to health care services Provider and Staff Feedback from providers Feedback from QI committees and stakeholder participation in other committees Satisfaction surveys, input from enrollees Provider onsite reviews, surveys of appointment availability and medical/treatment

record reviews.

Demographic data utilized is depicted in the following table Race/ethnicity and languages spoken by the MCC FL members.

Race/Ethnicity as of August 31, 2017 Count %

Caucasian 19,595 34.87%

Black 14,695 26.15%

Hispanic 10,212 18.17%

Not Provided 9,969 17.74%

Other Race 1,234 2.20%

Asian/Pacific Islander 361 0.64%

American Indian 133 0.24%

Language as of August 31, 2017 Count %

English 48,410 86.14%

Spanish 6,864 12.21%

Undetermined 761 1.35%

Creole 164 0.29%

Utilization data, complaint and grievance/appeals data

The largest complaint category related to Claims/Billing disputes (155

complaints/49.2%), followed by Managed Care Plan’s Administrative Functions (85 complaints/27.0%). Claims/Billing disputes increased by 15.7% from 2015 to


2016 with complaints related to MCC’s Administrative Functions increasing by 254.2%.

Claims/Billing disputes were mainly comprised of claim denials and payment

timeliness. The two largest sub-categories related to Administrative Functions were Magellan staff attitude/unprofessional behavior and responsiveness to inquiries. To address issues related to claim denials and payment timelines as well as provide consistent approach to assisting practitioners, MCC FL has established a dedicated sub-team in the Enrollee Services Department to manage claim issues and reprocess claims when appropriate.

Whenever a gap is identified from a utilization standpoint via the Health Guides, the information is quickly relayed in house and addressed appropriately. We also conduct weekly meetings where issues of utilization are addressed and a resolution is determined.

There were 248 provider complaints during 2017 as depicted in the following table; MCC is tracking and trending all provider complaints in order to source opportunities for internal process improvement and provider education actions:

Category # of Provider complaints as of August 31, 2017

Claims/Billing disputes 155

Managed Care Plan’s administrative functions, including proposed actions 24

Managed Care Plan’s policies and procedures 21

Service authorizations 48

Total: 248

There were 2,011 member complaints/grievances for an overall rate per thousand members of 27.37. MCC is tracking and trending member complaints beyond the resolution to identify opportunities for improvement in our internal operations and with network providers delivering care.

Category # of Member Complaints Rate per 1000

Quality of Care 182 0.18 Access 790 0.79 Attitude and Service 704 0.71 Billing and Financial 267 0.26 Quality of practitioner office site 68 0.06

As part of the quality improvement program, Magellan Complete Care employs data collection, monitoring, and reporting activities in order to continuously monitor providers to ensure they comply with appointment access standards; so that enrollees with Medical, Mental and Behavioral Health conditions are seen in a timely manner and individual service plan goals are met. This is accomplished through:


• Reviewing appointment logs during site visits. • Completion of training as described in this Network Development and Management plan to

include but not limited to; Customer Service Center Member Eligibility and Enrollment Assignment Member Benefits and covered services Outreach and Marketing (Do’s and Don’ts) Claims and Billing Clinical Team and Programs Complaints, Grievances, and Appeals Fraud, Waste, and Abuse Direct training for Providers surrounding the medical/psychiatric aspects of caring for

victims and perpetrators of physical/mental abuse, neglect, exploitation and domestic violence.

• Monitoring complaint indicators related to access • Evaluating enrollee, family, parents of children and adolescents, and other stakeholder

recommendations and incorporating into the network development plan. • Identifying providers to fill service or geographic gaps.

Conducting an annual survey of providers to evaluate the average number of calendar days for appointment availability. Variables measured include number of hours for crisis, urgent, and routine appointments; currently accepting new enrollees; in-office wait time; and any barriers to scheduling appointments with Enrollees.

MCC FL performed its annual analysis of data to measure its performance against its standards for access to regular and routine care appointments, urgent care appointments, and after-hours. In October of 2016 for a report due to AHCA in February 2016. The survey results are below:

Survey Population

Date Range of Sample

Well Care PG3 = 31 Days

Routine Office Visits NCQA = 10 Business Days

Sick Care PG2 = 7 Days

Urgent Care PG1 = 1 Day

Urgent Care NCQA = 48 Hrs.

1 of 2: Original Entries Non-Life-Threatening Emergency Care NCQA = 6 Hrs.

2 of 2: Entries As Hours Non-Life-Threatening Emergency Care NCQA = 6 Hrs.

State of FL 2016 98.8% 97.6% 89.9% 91.8% 95.2% 40.1% 71.9%

Quality Committee When performance indicator reviews or quality data suggest the need for a focused review of provider performance, targeted reviews are initiated and conducted by clinical reviewers or compliance auditors. Such issues as lack of access, limited availability, complaints, quality of care concerns and potential


fraud, waste and abuse are potential triggers for ad hoc reviews. They are conducted to ensure the safety of enrollees and to ensure best practices and established policies and procedures are being followed. Trending and tracking of findings from these reviews can lead to a Process Improvement Process (PIP), provider education, and/or system interventions which are then monitored for improvement and sustainability of performance. Magellan Complete Care has a robust committee structure to support the internal network monitoring process. Below is a chart that demonstrates the Quality committee structure and the touch points that are built to support network oversight and monitoring such as:

- MCC-FL Quality Improvement Committee - MCC- FL Compliance Committee - MCC-FL Peer Review and Credentialing Committee - MCC- FL Network Strategy Committee

Network Strategy Subcommittee Authority and Role


The Network Strategy Committee is chaired by the MCC FL Senior Director Network Management. The Network Strategy Committee reviews and approves network development and network expansion related functions, responds to provider terminations and availability and accessibility issues, plans for short and long term needs from the larger provider community. The committee also reviews provider claims, denial reports and percentages, reviews non participating provider utilization and focuses on area-specific initiatives related to training and development needs. The annual provider relations plan is reviewed and evaluated within this committee. The MCC FL Network Strategy Committee meets, at a minimum, quarterly. Functions

• Network Definition: define size, composition, and training needs of the network serving their

membership. • Ongoing establishment of Network maintenance and development priorities. • Evaluate the need for network membership by geographic territory on an ongoing basis, including

network saturation and need for specialty practitioners and providers. • Evaluate clinical needs for special populations or diagnostic categories. • Develop service resources for all levels of care and collaborate with existing providers for expansion. • Develop strategies for filling network gaps including review of ad hoc data.

Identify continuum of care needs to facilitate improved service delivery.

Membership (Minimum) • Senior Director Network Management (Chair) • Medical Director – BH • Sr. Area Contract Manager • Network Regional Director • VP Medical Director • Sr. Account Executives • Senior Director of Health Services • Quality Director or designee There is a mechanism to include external feedback and monitoring through our Physician Advisory Board (PAB) and Joint Operating Committees (JOC). The PAB occurs quarterly and is comprised of 13 physicians statewide from a variety of disciplines (including: PCP, psychiatry, pulmonology and substance abuse focuses). During the PAB meetings, Magellan Complete Care shares the plans current priorities, asks the doctors for feedback and recommendations to support those priorities, and reviews any new major changes or challenges. This group focuses on innovation and development by leveraging the thought leaders in the network to provide insight and expertise from a direct service perspective. Joint Operating Committees are monthly meeting conducted with key health systems, multi-disciplinary practices, vendors and high volume practitioners who account for significant utilization of Magellan Complete Care enrollees and those who manage and care for many high complex health care matters. These facilities and systems participate with respective health plan representatives as a way to proactively and collaboratively work through any issues or challenges. It also provides a forum for


feedback and partnership to develop creative ways to better serve the members and improve quality of care surrounding many of the important components below:

• Patient access to health care services and supplies • Authorizations & Referrals • Care Coordination and complex care management Utilization Management • Discharge Planning • Accounts Receivable and Claims Payment • Member Enrollment • Covered Benefits and Plan Design • Policies and Procedures • Quality Improvement • Contracting & Credentialing • Value based reimbursement

Network Design

The Network Development Plan describes the network design by region and county for the general population, including details regarding special populations as identified by the network management, health services and care coordination. MCC FL assesses the availability and accessibility of care and services at least annually to determine the extent to which MCC provides and maintains appropriate member access to primary care, high volume and high-impact specialty care, and behavioral health care services. Data sources utilized in this assessment include:

• Geo Access and Density Reports assessing provider availability • Member experience data, including satisfaction and complaints regarding the availability of

and access to services • Primary care practitioner self-report regarding access to regular, routine, urgent and after

hours care • Behavioral health practitioner self- report regarding access to emergent, urgent, routine

care, and follow-up to routine care • High volume and high-impact specialty practitioner report regarding appointment access

In order to ensure all covered services are available and accessible to members. Magellan pursued an aggressive timeframe for provider recruitment and credentialing completion. This allowed us to not only meet but exceed the requirements set forth by AHCA for availability and accessibility of acute, primary, institutional and community-based long-term services and supports (LTSS), behavioral health and special Medicaid services in both urban and rural areas. Magellan continually runs accessibility analysis reports to identify gaps in provider coverage, by specialty, as a result of changes in the network and quickly engages contractors to add respective specialties based on our member requirements. Identifying shortages in any provider category, Magellan strives to meet the standards set forth by AHCA for all specialties in all regions including at times, member requests for a provider that need to be fulfilled for a specialized provider.


Should Magellan be unable to secure a full provider agreement with identified providers, Magellan will utilize the Single case agreement process to ensure continuity of care for our members. This process will continue until we are able to provide the service with contracted and credentialed providers. Magellan is committed to continue building a robust provider network to ensure full access to services for our members The geographic location of providers and Medicaid enrollees by distance, travel time and means of transportation used by Medicaid enrollees. Magellan will comply with all network capacity and geographic access standards set forth by AHCA in the MCC FL Contract, specifically Section II and VII; Provider Network Standards and Network accessibility and Adequacy Our goal is to build a provider network that not only meets, but exceeds the AHCA minimum access requirements. This will be done though the continuous monitoring of our provider recruitment using various tools, inclusive of Quest Analytics software, which provides both access and adequacy reports based upon time, distance and quantity of providers. Specifically designed reports have been built to meet both the urban and rural county access standards to ensure Magellan’s success in building a dense and diverse pool of providers to meet member’s primary care and specialty care needs.

Network adequacy & accessibility requirements

Practitioner Type Measure Standard Actual Family Practice Practitioners to Members 1:1500 1:56 General Practice Practitioners to Members 1:1500 1:161 Internal Medicine Practitioners to Members 1:1500 1:50 Pediatrics Practitioners to Members 1:1500 1:50 Pediatric & Family Practice Practitioners to Pediatric Members 1:1500 1:13

Practitioner Type Measure Standard Actual Allergy Practitioner to Members 1:20,000 1:835 Ob/GYN Practitioners to Members 1:1500 1:123 Cardiology Practitioners to Members 1:3700 1:136 Endocrinology Practitioner to Members 1:25,000 1:847 Neurology Practitioners to Members 1:8300 1:227 Infectious Disease Practitioners to Members 1:6250 1:368 General Surgery Practitioners to Members 1:3500 1:175 Pulmonology Practitioners to Members 1:7600 1:362 Nephrology Practitioners to Members 1:11,000 1:360 Hematology/Oncology Practitioners to Members 1:5200 1:518 Optometry Practitioners to Members 1:1700 1:73 Gastroenterology Practitioners to Members 1:8333 1:221

Practitioner Type Measure Standard Actual Psychiatrist Practitioners to Members 1:1500 1:71 Mental Health Counselor Practitioners to Members 1:1500 1:35 Licensed Social Worker Practitioners to Members 1:1500 1:83 Child/Adolescent Psychiatrist Practitioners to Pediatric Members 1:7100 1:60 Clinical Psychologist Practitioners to Members 1:1500 1:218


Category Trimester Initial appointment

Pregnancy First 14 days Pregnancy Second 7 days Pregnancy Third 5 days High Risk - 3 days

Well Care A routine medical visit for one of the following: CHCUP (Florida Medicaid’s Child Health Care Check-Up) visit, family planning, routine follow-up to a previously treated condition or illness, adult physical or any other routine visit for other than the treatment of an illness.

< 1 month

(31 days)

Routine Care An appointment with no extenuating circumstances or sense of urgency. < 10 business

days Sick Care Services for non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated (e.g., chronic disease).

< 1 week (7 days)

Urgent Medical Care Services for conditions, which, though not life-threatening, could result in serious injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe pain) or substantially restrict an enrollee’s activity (e.g., infectious illnesses, influenza, respiratory ailments).

< 1 day

Urgent Behavioral Health Care Those situations that require immediate attention and assessment within twenty-three (23) hours even though the enrollee is not in immediate danger to self or others and is able to cooperate in treatment.

< 1 day

Urgent Care Care or treatment with respect to which the application of the time periods for making non-urgent care determinations could result in the following circumstances: (a) could seriously jeopardize the life, health, safety of the patient or others, or the patient's ability to regain maximum function, based on a prudent layperson's judgment or due to the patient’s psychological state, OR (b) in the opinion of a practitioner with knowledge of the patient's medical or BH condition, would subject the patient to severe pain or adverse health consequences that cannot be adequately managed without the care or treatment that is the subject of the request.

< 48 hours

Care for Non-Life-Threatening Emergency Services for a condition requiring rapid intervention to prevent acute deterioration of the patient's clinical state, such that gross impairment of functioning exists and is likely to result in compromise of the patient's safety. This condition is characterized by sudden onset, rapid deterioration of health, cognition, judgment, or behavior, and is time-limited in intensity and duration.

< 6 hours

Follow Up After Hospitalization for Mental Illness (behavioral health only): A behavioral health appointment after discharge from an acute inpatient setting (including acute care psychiatric facilities) with a principal mental health diagnosis psychiatric facility.

< 7 days

Emergency Medical Services1: Medical screening, examination and evaluation by a physician or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists. If such a condition exists, emergency services and care include the care or treatment necessary to relieve or eliminate the emergency medical condition within the service capability of the facility. These conditions are defined as: (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could result in any of the following: (1) serious jeopardy to the health of a patient, including a pregnant woman or fetus; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; OR (b) With respect to a pregnant woman: (1) that there is inadequate time to effect safe transfer to another hospital prior to delivery; (2) that a transfer may pose a threat to the health and safety of the patient or fetus; (3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.

Emergency Behavioral Health Services Those services required to meet the needs of an individual who is experiencing an acute crisis, resulting from a mental illness, which is a level of severity that would meet the requirements for an involuntary examination, and in the absence of a suitable alternative or psychiatric medication, would require hospitalization.

Results of monitoring activities shall be reported to the Network Strategy and Oversight Committee. An outcomes report is then coordinated with the Quality Improvement Committee to develop


appropriate interventions in response to any identified areas of sub-optimal performance, including ongoing monitoring for the implementation of interventions to support continuous improvement. Current Network Status

Managed Care Plan’s annual network plan must include a description or explanation of the current status of the network by each covered service at all levels including: How enrollees access services;

Magellan Complete Care’s is structured to offer a “no wrong door” approach for enrollees

seeking access to the system, allowing the ability for a enrollee to enter the system from multiple points of entry.

Enrollees may access Magellan's provider system through our staff outreach to the member, calling into our customer call center and through direct contact their medical providers. Magellan makes a consorted effort to remove any barriers to enrollee access that are identified. These barriers are addressed promptly and resolved with the appropriate timeliness required.

Selecting a PCP Enrollees primary care doctor (PCP) is their personal doctor who will oversee all their health care.

Enrollees have the right to choose any PCP that is part of Magellan’s robust provider network. Selection can be made from Magellan’s provider directory, our website, or calling 800-424-8584. A new provider directory can be mailed to enrollees if need. If enrollees do not choose a PCP, Magellan will choose one for them.

Enrollees may choose to have their whole family with the same PCP or they may choose a different PCP based on each family member’s needs.

A female enrollee may choose an obstetrician/gynecologist (OB/GYN) as her PCP if the OB/GYN agrees to serve as the PCP. If an enrollee wants to change their PCP, they may call Customer Service toll free at 800-424-8584

Enrollees may access at least one full-time equivalent (FTE) primary care provider (PCP), regardless of specialty type (pediatricians; family, and general practitioners; internists; obstetrician/gynecologists; specialists who perform primary care functions within clinic settings) for every 1,500 MCC FL program members (excluding dual eligible).

Enrollees may access at least one FTE PCP with pediatric training and/or experience for every 1,500 members under age 18.


In urban areas, enrollees will have a choice of at least two providers for each type of service (including LTSS) located within no more than 30 minutes travel time for any member.

In rural areas, enrollees will have a choice of at least two providers of each service type located within no more than 60 minutes of travel time from any member.

Enrollees will have a choice of at least two providers per service type located within no more than a 15-mile radius in urban areas and 30 miles in rural areas.

Enrollees will have at least two HCBS providers (other than community-based residential alternatives) in the member’s county or adjoining county.

Referral and approval for Specialty, Ancillary and Hospital Care

• If an enrollee needs to see a specialty doctor and they are a participating provider than an authorization is not necessary for a consultation

• The provider directory lists doctors and hospitals that are part of Magellan’s network For enrollees to self-select and self-refer

• If enrollee wishes to see a doctor not in the directory (not in our network), their PCP can contact Magellan for an approval.

• Magellan only gives approvals in special cases and normally do not pay for out-of-network care except emergency care and family planning services.

• Enrollees may be able to see a specialty doctor without getting an okay each time (standing referral) if they have a long-term illness. Enrollees PCP may contact Magellan to arrange this

• Enrollees may not need to call their PCP for a referral for medical and behavioral health appointments.

• Magellan utilizes a three-phase approach for enrollees to access covered services through directories of (on-line and paper) providers • Phase One

The Customer Service Center team is validating provider information. • Phase Two

The Network team and Provider Support Specialist are working closely during provider visits to ensure data accuracy and completeness.

• Phase Three Online approach to commence by June 2017 which will allow providers the

opportunity to submit adds, changes and deletions on our website. Provider Network Composition

Member Enrollment

Area Enrollment as of 8/1/2017


2 3625

4 7987

5 6784

6 11561

7 9624

9 6906

10 7340

11 16783

Total 68,610 Number and type of providers required to furnish contracted services

Specialty 2 4 5 6 7 9 10 11 Total

ADOLESCENT MEDICINE 1 2 1 6 3 1 2 6 22

ALLERGY 3 5 1 3 2 5 20 21 60

ANESTHESIOLOGY 23 86 27 32 49 82 112 211 622

CARDIOVASCULAR MEDICINE 25 60 33 49 56 55 73 108 459

DERMATOLOGY 1 18 14 26 20 14 11 62 166

DIABETES 1 1

EMERGENCY MEDICINE 31 93 19 55 46 31 162 42 479

ENDOCRINOLOGY 1 6 5 3 5 3 11 32 66

FAMILY PRACTICE 45 161 34 79 82 45 130 119 695

GASTROENTEROLOGY 7 79 4 18 23 23 42 40 236

GENERAL PRACTICE (DEFAULT SPEC FOR PHYS) 8 13 7 21 27 6 25 49 156

PREVENTIVE MEDICINE 1 1 2 4

GERIATRICS 3 1 2 2 4 12 24

GYNECOLOGY 1 1 1 4 2 1 1 11

HEMATOLOGY 5 11 25 24 26 15 43 60 209

IMMUNOLOGY 1 1

INFECTIOUS DISEASES 14 8 31 19 8 16 33 129

INTERNAL MEDICINE 41 107 35 106 183 99 198 296 1065

NEONATAL/PERINATAL 1 22 35 31 27 17 18 20 171

NEPHROLOGY 5 7 16 26 5 9 29 21 118

NEUROLOGY 6 33 10 37 19 20 43 75 243

NEUROLOGY/CHILDREN 2 6 2 2 8 1 6 5 32

NEUROPATHOLOGY 1 1

OBSTETRICS 2 2 4

OB-GYN 14 40 28 93 68 57 73 78 451

ONCOLOGY 5 16 10 27 22 11 23 10 124


OPHTHALMOLOGY 23 47 36 75 56 92 76 111 516

OTOLARYNGOLOGY 3 16 4 17 23 13 20 39 135

PATHOLOGY 3 11 4 10 7 7 15 38 95

PATHOLOGY, CLINICAL 10 15 3 28

PEDIATRICS 13 94 50 87 157 110 161 174 846

PEDIATRICS, ALLERGY 3 6 1 10

PEDIATRICS, CARDIOLOGY 1 11 28 27 16 16 22 25 146

PEDIATRICS, ONCOLOGY/HEMATOLOGY 2 7 13 9 14 10 8 63

PEDIATRICS, NEPHROLOGY 1 2 2 2 7 6 9 7 36

PHYSICAL MEDICINE AND REHAB 1 15 1 5 20 9 23 21 95

PSYCHIATRY 38 83 62 145 64 66 68 168 694

PSYCHIATRY, CHILD 15 36 26 32 29 48 29 39 254

PSYCHOANALYSIS 4 14 8 62 29 19 29 82 247

PULMONARY DISEASES 13 15 10 26 20 3 20 30 137

RADIOLOGY 14 3 5 3 5 27 13 70

RADIOLOGY, DIAGNOSTIC 5 96 37 74 56 114 91 97 570

RADIOLOGY, PEDIATRIC 22 6 25 10 10 11 84

RADIOLOGY, THERAPEUTIC 3 16 6 12 12 8 16 24 97

RHEUMATOLOGY 2 4 3 8 4 2 5 5 33

SURGERY, ABDOMINAL 1 1

SURGERY, CARDIOVASCULAR 3 5 7 13 5 8 12 12 65

SURGERY, COLON/RECTAL 3 4 2 1 5 7 22

SURGERY, GENERAL 15 32 13 55 36 38 36 77 302

SURGERY, HAND 4 2 3 1 1 2 13

SURGERY, NEUROLOGICAL 4 15 6 30 14 4 18 25 116

SURGERY, ORTHOPEDIC 21 23 12 30 22 11 36 46 201

SURGERY, PEDIATRIC 5 6 5 6 4 10 2 41

SURGERY, PLASTIC 11 5 12 7 8 7 8 58

SURGERY, THORACIC 1 7 4 2 9 8 14 13 58

SURGERY, TRAUMATIC 4 3 11 1 1 6 2 28

SURGERY, UROLOGICAL 1 3 1 4 9

MATERNAL/FETAL 1 7 6 12 7 6 10 4 66

MEDICAL OXYGEN RETAILER 1 1 2

GENERAL DENTISTRY 35 168 110 183 183 139 170 295 1283

ORAL SURGERY (DENTIST) 2 9 6 5 10 6 14 19 71

PEDODONTIST 3 12 11 16 16 12 32 39 141

OTHER DENTIST 1 15 6 10 10 9 18 21 90

ADULT PRIMARY CARE 8 6 5 11 3 8 5 7 53


CLINICAL NURSE SPECIALIST PSYCH. MENTAL HEALTH 23 35 29 45 35 17 23 22 229

FAMILY NURSE 46 86 25 91 50 50 40 122 533

GERIATRIC 2 1 3

CERTIFIED REGISTERED NURSE ANESTHETIST 32 90 38 19 86 69 139 182 617

OB/GYN NURSE 2 11 4 17 12 4 6 6 62

PEDIATRIC NURSE 46 12 35 24 12 11 13 153

ORTHODONTIST 2 6 4 5 9 5 4 8 43

OCCUPATIONAL THERAPIST 3 17 10 27 14 9 14 26 120

PHYSICAL THERAPIST 6 26 17 52 57 21 25 57 261

SPEECH THERAPIST 9 16 12 26 48 11 21 38 181

RESPIRATORY THERAPIST 1 4 2 3 3 1 6 9 33

DEVELOPMENTAL DISABILITY 4 7 3 3 6 23 6 6 58

GENETICS 7 1 4 9 4 7 32

PEDIATRICS, CRITICAL CARE 10 13 7 2 32

PEDIATRICS, EMERGENCY CARE 1 23 1 17 8 11 9 70

SURGERY, UROLOGIC - NON-BOARD CERTIFIED 1 1

ASSISTED LIVING 16 78 53 180 176 60 206 851 1709

ADULT FAMILY CARE HOME 3 15 6 14 14 9 5 7 73

RESIDENTIAL TREATMENT FACILITY 1 1 1 3

ANESTHESIOLOGY ASSISTANT 1 1

HOSPITALIST 13 20 7 25 33 2 25 44 169

COMMUNITY PHARMACY 148 440 391 597 591 452 432 625 3676

INFUSION PHARMACY 1 2 1 4

LTC - NON COMMUNITY 1 1

RNFA 1 1 1 1 4

HOSPITAL WITH BIRTH/DELIVERY SERVICES 2 1 2 2 7

EMERGENCY SERVICES 1 4

ENDOCRINOLOGY (PEDS) 1 12 5 6 12 2 7 5 50

UROLOGY 1 11 6 18 12 5 28 21 102 PSYCHIATRIC COMMUNITY HOSPITAL/CSU CAP ONLY ADULT 9 6 8 3 8 5 10 49 PSYCHIATRIC COMMUNITY HOSPITAL/CSU CAP ONLY CHILD 1 4 2 2 9

MANAGED CARE TREATING PROVIDER - OTHER 1 1 1 3

GENERAL HOSPITAL 11 10 11 13 21 14 8 8 96

COMMUNITY MENTAL HEALTH SERVICES 28 57 37 64 71 49 33 60 399

AMBULATORY SURGERY CENTER 1 6 2 3 9 7 3 31

SPECIALIZED MENTAL HEALTH PRACTITIONER 67 186 191 265 285 116 102 259 1471

SKILLED NURSING FACILITY 2 17 10 20 14 7 3 3 76


HOSPICE 6 12 3 2 10 9 2 9 53

PODIATRIST 2 20 11 17 27 26 29 36 168

CHIROPRACTOR 8 18 33 32 47 32 37 28 235

PHYSICIAN ASSISTANT 39 131 33 71 51 47 83 72 527

NURSE PRACTITIONER (ARNP) - GROUP 1 2 1 1 5

SOCIAL WORKER/CASE MANAGER 48 66 74 112 92 80 70 118 660

LICENSED MIDWIFE 4 7 2 25 2 19 14 12 85

NON-PROFIT TRANSPORTATION 1 1

INDEPENDENT LABORATORY 18 49 31 49 54 52 32 37 322

PORTABLE X-RAY COMPANY 1 1

AUDIOLOGIST 6 19 6 23 15 12 21 21 123

HEARING AID SPECIALIST 5 3 3 12 11 12 4 10 60

OPTOMETRIST 33 63 82 170 115 100 63 65 566

HOME HEALTH AGENCY 8 22 12 19 16 8 10 32 127

RURAL HEALTH CLINIC 1 1

FEDERALLY QUALIFIED HEALTH CENTER 1 3 4

BIRTH CENTER 1 1 1 1 1 1 6

COUNTY HEALTH DEPARTMENT 1 1

DIALYSIS CENTER 1 15 7 11 10 12 7 12 105

DURABLE MED EQUIPT/ MEDICAL SUPPLIES 14 16 7 17 26 27 16 24 255

CASE MANAGEMENT AGENCY 1 1 2

Grand Total 1789 3879 4231 4601 5224 2987 3889 5772 32245

Disease management impacting network access

MCC’s experience has taught us that a significant proportion of the population requires

disease management support to manage their chronic conditions. Nearly half, 53 percent


of the SMI non-dual population has one or more of the core chronic conditions, as follows with the dual beneficiaries having an even higher percentage:

Based on analysis of its population and prevalence of conditions seen, MCC FL’s disease management activities focused on the following condition-specific programs: Asthma, Cancer, Diabetes and Hypertension.

The table below presents the population within MCC FL with the designated condition for the four disease management programs in place during 2016. Program Percent of Population Diagnosed with Condition

2016 Asthma 5,601 (12.4%) Cancer 765 (1.7 %) Diabetes 3,696 (8.2%) Hypertension 9,935 (21.8 %)

In order to manage these conditions, we expect higher utilization of following services and will ensure our network of providers is robust to offer the member choice: MCC develop and maintains Network for adequacy and accessibility as it may relate to enrollees with chronic conditions. These areas include: Degenerative and inflammatory joint disease, inflammation, and related pain - 29 percent

of the population Gastro-intestinal conditions - 22 percent Orthopedic trauma and fractures - 21 percent Pregnancy related care, prenatal through postpartum care, parenting support, and care

for newborns. (Projected to involve 7 percent annually of adult females with SMI.) Behavioral Health Services Substance use services Diabetes care, medications and supplies

Primary care Endocrinology

• Care for respiratory illness Pulmonary specialists Pulmonary testing

• Cardiac care Cardiologists, Cardiac testing Preventive interventions for heart disease • Orthopedic care • Pain management • GI specialty care • Treatment for obesity

Physical accessibility for Medicaid enrollees

MCC of FL recognizes that there are geographical areas within the state of Florida that lack a sufficient number of particular specialties, especially the Southwest Region where the available providers to select let alone contract with, is limited. Therefore, we continue to explore


opportunities to address these situations through contracting, management, use of single case agreements, technological advances, non-emergency transportation, and provider incentives to ensure all enrollees maintain sufficient access to providers. Results of the network sufficiency analysis help ensure service types and capacity meet system needs including culturally diverse priority populations and persons with special needs. 24-Hour Coverage: All providers must provide 24 hours a day/seven days a week coverage. Regular hours of operation must be clearly defined and communicated to the members, including arranging for on-call and after-hours coverage. Such coverage must consist of an answering service, call forwarding, provider call coverage or other customary means approved by Magellan Complete Care of Florida such as referral to member’s primary care provider, an urgent care facility or referral for emergent matters to a local Emergency Center by dialing 911. The after-hours coverage must be accessible using the medical office’s daytime telephone number and the call must be returned within 30 minutes of the initial contact. Coverage during Absence: Providers must arrange for coverage of services during absences due to vacation, illness, or other situations that require the provider to be unable to provide services. A Magellan Complete Care of Florida participating provider must provide coverage. Magellan’s program capitalizes on Magellan‘s success in ensuring covered services are easily accessible to enrollees with limited English proficiency and those with hearing and visual impairments. We will ensure all services, including those provided by our contracted providers, are fully compliant with the Americans with Disabilities (ADA) requirements. Enabling our enrollees to fully benefit from treatment services is, in part, a function of understanding and respecting an enrollee‘s culture and heritage and using language as one of the ways of addressing barriers to treatment. Magellan ensures provider compliance with Americans with Disabilities (ADA) requirements. Compliance with ADA guidelines is a component of Magellan‘s provider contracts and is reviewed as part of the credentialing and re-credentialing process. Our quality management staff routinely monitors enrollee complaints and grievances and will perform a site visit and provider education if warranted. If a provider is found to be out of compliance with ADA guidelines, the provider will receive a corrective action plan. Magellan will offer education and technical assistance. If the provider does not achieve compliance with the ADA guidelines, Magellan Complete Care will consider terminating them from the network, after considering access to care impacts. Magellan Complete Care monitors compliance with accessibility by review of Provider’s credentialing and re-credentialing applications, periodic survey of providers through the quality improvement process and through periodic site visits, ongoing orientation and training and through defined field visits to providers through POD personnel assigned to the provider.

Subcontractor Providers MCC of FL selected the following subcontractors to further enhance our broad network adequacy and accessibility in the delivery and implementation of the obligations in ensuring network adequacy and accessibility to include the following:


Magellan Rx Management, Inc. – Pharmacy Benefits Management National Imaging Associates, Inc. (NIA) – Specialty Health Care Management Veyo – Transportation Services DentaQuest – Dental Benefits Management Premier Eye Care – Vision Benefits Management Engaging Solutions – Outbound Calls PurFoods, LLC – Home Nutrition Solutions Integra − Locates Members that Active Outreach Efforts are Unable to Find Astyra – Staffing Agency for Call Center

We continue to monitor the performance of our subcontractors to ensure contract compliance, including program integrity responsibilities. This is accomplished through a dedicated Delegation Oversight Program that focuses on mitigating the risks and optimizing the opportunities associated with delegation. The outcomes of delegated vendor oversight are reported to the Compliance Committee and issues are brought to the Board of Directors through the Contract Compliance Officer. Through our oversight and auditing processes, we are able to assess the effectiveness of our subcontract programs and apply corrective actions as necessary to ensure network adequacy and accessibility for MCC of FL enrollees. We continue to utilize our current contract with Global Interpreting to provide a robust network of qualified interpreter services to accompany our enrollees with limited English proficiency or hearing impairments to appointments. We will work with our network providers to ensure they are aware of this resource for our enrollee appointments. Magellan does not support the use of family members and friends to fulfill this function. In addition to 24/7 availability and no scheduling restrictions, we require vendors to have established and measurable standards and training for its health care interpreters that meet the standards currently recommended by the National Council on Interpretation in Health Care. If an enrollee prefers or time does not allow for on-site services, Magellan will provide 24/7 access to telephone interpreters through our current contract with Pacific Interpreters to provide assistance to enrollees when they are in a clinical setting. In addition, Magellan is exploring the suitability of video access to interpreters where practical and appropriate. To provide high quality and responsive Non-Emergency Transportation services, we require all third-party providers attend a mandatory Magellan Complete Care or State initiated driver training program to ensure the driver provider understand and comply with their Magellan contracts with Veyo transportation services allowing us to meet the non-emergency transportation needs of enrollees with Mental and Behavioral Health experiences. Vehicles are required to meet Federal and State standards for vehicle safety and, including meeting the Americans with Disabilities Act (ADA) requirements.

Barriers to Network Adequacy & Accessibility

As part of our network monitoring and accessibility capacity measurement process, we use industry accepted quest analytics and GeoAccess mapping that appropriately evaluates membership detail against a set of defined network access standards required for each line of


business. We establish provider-to-member ratios by specialty type based on the populations served throughout the MCC of Florida service regions. For example, in Medicaid products we enhanced availability targets for such specialties as podiatry, orthopedics, and gerontology. In addition, we strive for higher ratios of available pediatricians, behavioral health specialists such as psychiatrists and physicians certified in addiction medicine, and community-based specialty behavioral health providers. Beyond the standard GeoAccess review process outlined above, we also rely upon additional network adequacy and accessibility evaluation elements to include the following: Ongoing active evaluation of network additions and terminations, including identifying

trends or particular providers through Provider Relations and Clinical Teams Appointment access standard reviews; our provider contracts outline requirements to

comply with appointment access standard timelines. Providers are educated on the standards, and compliance is measured through appointment test cases and other random sampling techniques

Results of our annual provider satisfaction surveys incorporate feedback from network participants on satisfaction of available providers

Evaluation of Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results that evaluate member satisfaction with access to care

Review of physician panel size and capacity to serve challenging members.

As issues are identified in any of the above areas, we take appropriate action to address and resolve them to ensure sufficient capacity and member choice including the following steps;

Immediate short-term interventions to address network gaps and resolve barriers;

Magellan will utilize single case agreements to meet the needs of our enrollees until

specified provider types and/or locations can be contracted and brought in-network. Single case agreements continue to facilitate our expediency of services whenever a provider within a certain region does not have specific appointment times that would satisfy the member’s needs. This has allowed us to be successful in not only facilitating satisfactory services but also bolstering our provider ranks wherever a greater need based on utilization is identified. Once these providers were engaged, they saw not only the usefulness their services could render to our members but also, how to be an integral part of the Magellan model of care.

Engage current provider partners to become “champions” of Magellan as a means of recruiting those MDs that work closely together and that could close the network gap. As a result, various FQHCs and provider groups have been instrumental in recommending specialists throughout the community which they have utilized in the past, or by facilitating contractual talks in order to expand the network.

If geographic accessibility issues are present, Magellan will provide transportation to the necessary provider type within the closest proximity, as appropriate.

Longer-term interventions to fill network gaps and resolve barriers;


Magellan will utilize single case agreements to meet the needs of our enrollees until specified provider types and/or locations can be contracted and brought in-network. Single case agreements have proven instrumental in identifying providers that were otherwise not available for contracting due to lack of identification in a specific area. These, coupled with member requests, are what have allowed us to facilitate services as needed in a prompt manner.

In areas where particular specialties do not have an adequate number of providers to satisfy Magellan member’s needs Magellan will continue to pursue contracts with regional provider groups. In some cases this will require contracting from outside the immediate area. May need to work with such provider groups to import those specialists into the area to offer those specialty services. Though we meet the accessibility standards set forth by AHCA, there are seldom cases where members request that the accessibility of specific providers be more stringent.

If geographic accessibility issues are present, Magellan will provide transportation to the necessary provider type within the closest proximity, as appropriate. We currently utilize Veyo to facilitate this process and although we currently do not have any accessibility issues, Veyo continues to be a stalwart partner in addressing these transportation requests as they have in the past.

Identify possible recruitment strategies for provider’s not-participating (i.e. provider incentives). In some cases, rates far exceeding the AHCA standards are required in order to achieve a contractual agreement in some rural areas and for some specialties.

Magellan has a wide array of service providers who perform different roles within

the service delivery network. Depending upon the provider’s role, Magellan considers different elements when monitoring capacity. The primary elements reviewed to monitor capacity within the provider network are: Quest Analytics provider access and adequacy reports Analysis and trending of enrollee provider accessibility complaints Enrollee satisfaction survey results Appointment & Timeliness of services Current Utilization Staffing Patterns Length of Stay Number of Active Enrollments Number of referrals and referral patterns Single Case Agreement Utilization Complaints Data Geographic Accessibility

Ongoing activities for network development based on identified gaps and future needs projection. Magellan Medical Director outreach to community providers Continuous provider recruitment


Participation in local medical associations Relationships with state medical schools and GME programs

Network Benchmarks and Standards are established in the contract between AHCA and Magellan. Magellan then requires providers to meet the minimum expectations via contractual requirement language. In addition, if areas are identified as potentially needing review for possible benchmark or standards revision, the QI Committee and its workgroups review and address the identified areas.

Regional Network Notifications

The Managed Care Plan shall notify AHCA within seven (7) business days of any significant changes to its regional provider network. A significant change is defined as follows:

(1) Any change that would cause more than five percent (5%) of enrollees in the region to change the location where services are received or rendered; or

(2) For MMA Managed Care Plans, a decrease in the total number of PCPs by more than five percent (5%).

Magellan adheres to the AHCA Regional Network Notification requirements as outlined in the Magellan Contract.

Documents

MMA SRC #11, Attachment 1: Network Development and ... 08/MAGELLAN/Exhibit A-4-… · 1—Magellan Complete Care Network Development & Management Plan MMA SRC #11, Attachment 1: Magellan